Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Tuesday, May 23, 2006

I guess I ought to say something

Followers of the public health scene (by which I mean what's happenin', who's down with who and what's up with that) may have noticed some controversy among various people about the magnitude of the danger of pandemic flu in general, and more specifically by a virus strain currently circulating in birds called H5N1. As I'm sure you know, it seldom infects humans, but when it does, it is quite likely to kill them. Many people are concerned that it may mutate into a form which can be efficiently transmittted among people, leading to a destructive worldwide pandemic. Others think this is unlikely.

Among the contestants are Revere of Effect Measure, who has occasionally filled in here while I've been gallivanting about the countryside, and for whom I have filled in while he's been gallivanting* about the planet, and Marc Siegel, with whom I have corresponded and spoken on one occasion at some length. I have been reluctant to say much about this because it's all gotten a bit personal, and I really, truly, want no part of that. But there are issues here that happen to be important to me, so the bullet I must bite.

Marc has summarized his position in the new issue of The Nation. He accuses the U.S. Centers for Disease Control and the World Health Organization of fueling a "worldwide overreaction to H5N1 avian influenza." Revere, in contrast, started raising the alarm about H5N1 influenza at a time when he viewed the CDC and U.S. response, at least, as an underreaction, and the WHO, while not necessarily insufficiently concerned, as having insufficient resources and insufficient cooperation from many national governments.

So this argument is largely a matter of degree. Siegel does not deny that it is possible that H5N1 will evolve into a human pandemic strain, although he considers it very unlikely. However, Marc says, quite specifically, "the priority being placed on it as a potential threat to humans is obscuring diseases that are already worlwide killers: malaria . . . tuberculosis. . . and HIV." He points out that these diseases already kill a lot of people, and that worldwide spending for HIV prevention and treatment is well below what WHO believes is needed. He further notes that the latest administration budget proposes cutting funding for HIV research at NIH, while slightly increasing funding for "avian flu and biodefense" research. He then goes on to talk about the money being wasted on project Bioshield, which is a boondoggle project for terrorism defense.

I am certainly sympathetic to Marc's rhetoric about insufficient global spending on important endemic diseases. I have written about this issue many times, including here and here. But it seems largely a red herring in this context. There is no evidence whatsoever that spending on pandemic flu preparations has displaced spending on other global public health priorities. Indeed, Marc seems to contradict himself by invoking WHO as the authority for saying that spending on HIV is insufficient. If WHO is calling for billions more to be spent on HIV, then how can he say that avian flu has somehow made WHO ignore other priorities?

The Bush administration's determination to squander billions on preposterous defenses against highly unlikely bioterrorism scenarios goes back to well before they had, apparently, even heard of H5N1 influenza. What has happened is that, rather than actually directing any new money to pandemic flu preparedness, they have simply added pandemic flu to the mission statement of their existing biodefense programs. That's actually a step forward, in my view. I have told this story here:

There isn't much in the way of a pandemic flu program per se; rather, states are expected to make preparations using two main sources of federal money, the U.S. Health Resources and Services Administration's National Bioterrorism Hospital Preparedness Program (HRSA-NBHPP) and the U.S. Centers for Disease Control and Prevention (CDC) Public Health Preparedness and Response for Bioterrorism Cooperative Agreement.

The word "bioterrorism" in the names of these programs comes from the days when the Bush administration assumed that bioterrorism was the only infectious disease threat facing the country. In Federal Fiscal Year 2004, when they first noticed the possibility of a naturally caused epidemic, the definition of the kinds of emergencies states were supposed to prepare for using these funds was broadened. Hence the CDC program is now called Cooperative Agreement for Public Health Emergency Preparedness, and the HRSA program's mission statement is "is to prepare hospitals and supporting healthcare systems, in collaboration with other partners, to deliver coordinated and effective care to victims of terrorism and other public health emergencies." [emphasis added.]

So, what happened when pandemic flu was added to the scope of these programs? The funds were cut, rather drastically. The HRSA program peaked in FY 2004, and funding declined slightly in FY 2005. I only have the figures for Massachusetts -- $10,686,180 in FY 2004, $10,256,868 in FY 2005 -- but you can find out about your own state's funding if you like at the HRSA web site. The CDC program really got wacked -- Massachusetts' funding in CDC budget year 8/31/03-8/31/04 was $21,141,965. Since then, it's been less than $18 million. The states use part of this funding to support preparedness by local health departments, and that's how the federal money trickles down to the local level. Obviously, that pass-through funding also peaked in 2004 and has been much less since then.

Siegel makes a case for investing in vaccine research and manufacturing facilities, which is one thing that Revere has also advocated for. Marc then decries the mass culling of poultry in response to outbreaks. I tend to agree with him that this is not helpful and takes a huge toll on the welfare of poor people who depend on poultry for food and income. Revere happens to agree.

Marc then criticizes the ABC movie Fatal Contact: Bird Flu in America, for "capitaliz[ing] on fear." Well sure. It's a disaster movie for crying out loud, that's what they do. There was a movie last night about an earthquake ripping North America in half. There are ridiculous, over the top disaster movies about volcanoes, tornadoes, extraterrestrial invasions, asteroids hitting the earth, giant monsters emerging from the bottom of the ocean, you name it. So what?

Finally, Marc says: "Sadly, hyperbole is not a method of discourse exclusive to TV drama; a public health blog for bird flu fanatics recently suggested that the United States should pull out of Iraq and use the resources we save for bird flu preparation. On the surface this sounds like a terrific idea. On further reflection it seems clear that going into Iraq in the first place was based on the same kind of argument -- in which a remote but scary risk is exaggerated so it appears to be looming -- that has characterized the public health reaction to bird flu."

Now, I must say I don't get this at all. I haven't heard of any blogger recommending that we spend the $2 trillion being squandered in Iraq on bird flu preparation, but it is certainly true that if we weren't wasting that money we could make adequate preparations for just about every possible disaster and make huge strides toward solving our more immediate problems as well. On the other hand, I don't see how anybody can make a credible claim that vast resources are being wasted on bird flu preparation. (And we certainly aren't killing hundreds of thousands of people and destroying a whole society in the process.) On the contrary, we are spending trivial amounts on these preparations, almost all of which Marc Siegel supports -- in fact he wants to spend more on vaccine resarch and development! His complaints about Project Bioshield are completely off topic and irrelevant.

Virologists and epidemiologists disagree about the likelihood that the specific viral strain H5N1, currently panzootic in birds, will evolve into a form which is readily transmissible from human to human. They disagree about the likely consequences if it does -- what the infection rate will be worldwide, how many people will become seriously ill, and how many will die. People also disagree on the extent of economic damage and secondary public health consequences -- from such causes as temporary shortages of health care workers, disruptions in the food supply chain, etc. -- that are likely to occur. But it would be grossly irresponsible to dismiss the possibility of a very destructive event. Nobody actually knows how likely it is, they merely have opinions.

Furthermore, no-one disputes that it is entirely possible that someday, one or another strain of virus will cause an emergency, be it worldwide or limited to a region or a continent. Influenza -- H5N1 or another strain -- is one possible candidate, but it could be something else. Nobody can actually assign a probability to an event of any given magnitude, or say when it will happen, but it almost certainly will. Humanity has endured destructive epidemics innumerable times in the past and we haven't repealed the principles of biology. It is prudent to make preparations for such an event. Preparations are not specific to H5N1 influenza. Whatever plans and infrastructure we put in place will be equally relevant to any other infectious disease outbreak. It is entirely reasonable for people to advocate for such investments, and equally reasonable to keep a watchful eye on H5N1.

So, the bottom line is, I really can't figure out what this argument is all about. Can you?

*Gallivanting seems to exist only in the present participle. Nobody ever gallivants, or gallivanted, but many are gallivanting.